Advanced cardiac MR imaging of ischemic heart disease

Cardiac MRI of acute coronary syndrome

Acute coronary syndrome (ACS) is a major cause of morbidity and mortality worldwide. New serological biomarkers, such as troponins, have improved the diagnosis of ACS; however, the diagnosis of ACS can still be difficult as there is marked heterogeneity in its presentation and significant overlap with other disorders presenting with chest pain. Evidence is accumulating that cardiac MRI provides information that can aid the detection and differential diagnosis of ACS, guide clinical decision-making and improve risk-stratification after an event. In this review, we present the relevant cardiac MRI techniques that can be used to detect ACS accurately, provide differential diagnosis, identify the sequelae of ACS, and determine prognostication after ACS.

Cardiac imaging: Part 1, MR pulse sequences, imaging planes, and basic anatomy

OBJECTIVE

MRI is a well-established modality for evaluating congenital and acquired cardiac diseases. This article reviews the latest pulse sequences used for cardiac MRI. In addition, the standard cardiac imaging planes and corresponding anatomy are described and illustrated.

CONCLUSION

Familiarity with the basic pulse sequences, imaging planes, and anatomy pertaining to cardiac MRI is essential to formulate optimal protocols and interpretations.

Pharmacological stress cardiovascular magnetic resonance

Over the past decade, cardiovascular magnetic resonance (CMR) has evolved into a cardiac stress testing modality that can be used to diagnose myocardial ischemia using intravenous dobutamine or vasodilator perfusion agents such as adenosine or dipyridamole. Because CMR produces high-resolution tomographic images of the human heart in multiple imaging planes, it has become a highly attractive noninvasive testing modality for those suspected of having myocardial ischemia. The purpose of this article is to review the clinical, diagnostic, and prognostic utility of stress CMR testing for patients with (or suspected of having) coronary artery disease.

The 20 year evolution of dobutamine stress cardiovascular magnetic resonance

Over the past 20 years, investigators world-wide have developed and utilized dobutamine magnetic resonance stress testing procedures for the purpose of identifying ischemia, viability, and cardiac prognosis. This article traces these developments and reviews the data utilized to substantiate this relatively new noninvasive imaging procedure.

Clinical applications of cardiac CT angiography

ECG-gated multislice CT provides a cost-effective, non-invasive technology for evaluation of the coronary arteries, as well as for additional clinical applications, which require morphological assessment of the heart and adjacent structures with simultaneous evaluation of the coronary circulation.The excellent negative predictive value of a normal coronary CTA (cCTA) examination excludes the presence of significant coronary disease in the symptomatic patient. Triple rule-out studies provide evaluation of the aorta and pulmonary arteries without loss of image quality in the coronary circulation. The ability to visualize surrounding vascular structures along with the coronary arteries is essential in the evaluation of coronary anomalies.Cardiac CTA is useful in non-coronary applications, including evaluation of the thoracic aorta, cardiac valves and other aspects of cardiac morphology that may require surgical or percutaneous repair. Although radiation exposure is a limitation of cCTA relative to echocardiography and MRI, recent technological advances allow coronary imaging with effective doses as low as 1 mSv.Recent advances in evaluation of coronary plaque morphology as well as myocardial perfusion will allow a more complete noninvasive cardiac assessment in the future and may provide a highly effective method of cardiac risk stratification to facilitate preventive cardiac care.

Balanced left ventricular myocardial SSFP-tagging at 1.5T and 3T

The purpose of the study was to evaluate the performance of steady-state free precession (SSFP)-tagging at 1.5T and 3T and to define the ideal settings with respect to optimized tag contrast throughout the cardiac cycle for both field strengths. To identify optimal imaging parameters data acquisition was repeated for different flip angles. Left ventricular tag-tissue contrast, tag fading times, tag persistence, and myocardial signal-to-noise ratio (SNR) were quantified in basal, mid-ventricular, and apical slice locations. To assess the effect of field strength on image quality and artifact level, additional semiquantitative image grading was performed by two experienced readers. SSFP-tagging at 3T proved superior to 1.5T and provided significantly enhanced tag persistence and myocardial SNR while maintaining overall image quality and artifact level. The definition of a tag quality index demonstrated optimal SSFP-tagging performance for a flip angle of 20 degrees . Diastolic tag visibility was improved at 3T and resulted in enhanced average tag persistence of 789 +/- 128 ms compared to 523 +/- 40 ms at 1.5T. For SSFP-tagging at 3T the combination of T(1) lengthening and superior myocardial SNR is highly promising and has the potential to improve the depiction of tagged myocardial function throughout the entire cardiac cycle.

Computational cardiac atlases: from patient to population and back

Integrative models of cardiac physiology are important for understanding disease and planning intervention. Multimodal cardiovascular imaging plays an important role in defining the computational domain, the boundary/initial conditions, and tissue function and properties. Computational models can then be personalized through information derived from in vivo and, when possible, non-invasive images. Efforts are now established to provide Web-accessible structural and functional atlases of the normal and pathological heart for clinical, research and educational purposes. Efficient and robust statistical representations of cardiac morphology and morphodynamics can thereby be obtained, enabling quantitative analysis of images based on such representations. Statistical models of shape and appearance can be built automatically from large populations of image datasets by minimizing manual intervention and data collection. These methods facilitate statistical analysis of regional heart shape and wall motion characteristics across population groups, via the application of parametric mathematical modelling tools. These parametric modelling tools and associated ontological schema also facilitate data fusion between different imaging protocols and modalities as well as other data sources. Statistical priors can also be used to support cardiac image analysis with applications to advanced quantification and subject-specific simulations of computational physiology.

MRI for the diagnosis of left ventricular apical ballooning syndrome (LVABS)

To compare MRI findings of left ventricular apical ballooning syndrome (LVABS) with those of acute myocardial infarction (AMI). Fifteen patients with a LVABS (group 1) and 25 patients with an AMI (group 2) were explored by MRI within 24 h after admission. Comparison of both groups for the number and location of myocardial segments with abnormal wall motion and abnormal perfusion or delayed enhancement was performed. The number of involved segments was higher in group 1 than in group 2 (p<0.001). In group 1, segments with abnormal wall motion were distributed in more than one vascular territory in all patients and confined to the medial, distal, and apical regions of the left ventricle. Subendocardial hypoenhancement was observed in 16/25 patients (64%) in group 2 and in none of group 1 (p<0.001). All patients in group 2 demonstrated delayed-enhancement abnormalities in a vascular distribution, whereas none in group 1 presented this abnormality (p<0.001). Diffusely distributed segmental wall-motion abnormalities and absence of first-pass perfusion hypoenhancement and of delayed enhancement at MRI help to differentiate LVABS from AMI. In the acute phase or in some difficult cases, cardiac MRI should become routine to confirm the diagnosis of LVABS.

Cardiac magnetic resonance imaging at 3.0 T

Cardiovascular magnetic resonance imaging (MRI) has gained widespread acceptance for the assessment of cardiovascular disease. Cardiac MRI requires fast data acquisition schemes because of constraints imposed by physiological motion of cardiac structures and blood flow, which dictate the suitable window of data acquisition. The ongoing improvement of MRI hardware and the development of tailored imaging techniques have been the cornerstones for rapid progress in cardiac MRI. Cardiac MRI at 3.0 T holds the promise to overcome some of the signal-to-noise (SNR) limitations, especially for techniques with borderline SNR at 1.5 T (eg, myocardial perfusion, assessment of viability, or imaging of coronary arteries). The improved SNR at 3.0 T can be used to increase the spatial resolution and/or reduce imaging time. It was shown that all applications of cardiac imaging at 1.5 T seem feasible also at 3.0 T and predominantly provide similar or improved image quality. Although specific absorption rate limitations and susceptibility effects remain a primary concern, the combination of high-field strength examinations with parallel imaging has increased the performance of techniques such as steady-state free-precession at 3.0 T. Therefore, the signal-to-noise and the contrast-to-noise ratios advantages at 3.0 T and the resulting potential benefit for an improved diagnostic value will constantly fuel further developments in this area and pave the way for novel, promising imaging techniques.

[Diagnostic imaging techniques for analyzing heart function: indications and limitations]

Cardiac function analysis is critical in the management of patients with cardiovascular diseases. The two most common non-invasive techniques used nowadays to evaluate cardiac function are ultrasonography and magnetic resonance imaging (MR). The parameters to be determined with both techniques include the systolic volume of the left ventricle, the cardiac mass, myocardial thickness and ejection fraction. Ultrasound images have high resolution and they do not need any cardiac or respiratory gating. It has limitations in obese patients, patients with pulmonary obstructive disease or patients after thoracic surgery. MR has a high spatial and temporal resolution. There are different sequences we can use to determine cardiac function parameters, Gradient Echo sequences are used to analyze the ventricular volume and the ejection fraction. Myocardial tagging sequences are used to quantify the myocardial wall motion. Computed Tomography constitutes other alternative that can be used in patients with claustrophobia or pace markers to evaluate cardiac function.

Assessment of myocardial viability in a reperfused porcine model: evaluation of different MSCT contrast protocols in acute and subacute infarct stages in comparison with MRI

OBJECTIVE

To assess myocardial viability in acute and subacute infarcts using different multislice spiral computed tomography contrast protocols with magnetic resonance imaging (MRI) correlation.

METHODS

Seven pigs were studied with 64-multislice spiral computed tomography and MRI (1.5 T) at a median of 1 and 21 days after temporary occlusion of the second diagonal branch. Computed tomography was performed at 3, 5, 10, and 15 minutes after injection of contrast medium. Contrast agent was applied either as a bolus (protocol 1; n = 7 for the first; n = 5 for the second scan) or as a bolus plus 30 mL of subsequent 0.1 mL/s low-flow (protocol 2; n = 7 for the first; n = 6 for the second scan). Finally, histological sections were obtained. Volumes of infarcted myocardium were assessed as the percentage of the left ventricle. Computed tomography attenuation values were obtained, and image quality was assessed.

RESULTS

When compared with protocol 1, protocol 2 provided greater Hounsfield unit attenuation difference between viable and nonviable myocardium at 5, 10, and 15 minutes (P = 0.19; 0.003; 0.0006) and an additional significant contrast between nonviable myocardium and ventricular blood at 3 and 5 minutes (P < 0.001). Image quality was rated significantly higher with the use of protocol 2 at 5, 10, and 15 minutes (P < or = 0.027) and for all time points use of protocol 2 resulted in improved correlation of acute and subacute infarct size with MRI.

CONCLUSIONS

Good correlation of infarct zones with MRI was achieved for both acute and subacute infarcts. With the use of a bolus/low-flow protocol, image quality was substantially improved by means of a higher tissue contrast.

Establishing a cardiac MRI program: problems, pitfalls, expectations

Magnetic resonance imaging (MRI) has been used to evaluate the cardiovascular system for almost 2 decades. Although vascular applications have been robust and steadily improving for many years, the utility of MRI for clinical cardiac imaging has been limited. However, recent advances in hardware technology and pulse sequence design have led to substantial improvements in image quality, while reducing scan times to clinically reasonable durations. Pulse sequences using electrocardiographic gating and k-space segmentation have made it possible to obtain high-contrast, high-resolution images of the beating heart within single breath-holds. These images in turn have provided unprecedented visualization of myocardial morphology and function. Because of these developments, cardiac MRI (CMR) has made rapid and dramatic inroads into the clinical arena. Currently, the primary limitations to routine clinical application are hardware availability, clinical acceptance, politics, examination cost, and not least of all physician education. As these limitations are overcome or made more manageable, the clinical use of CMR will grow, potentially without bound. Combined with steady hardware development and an ever-growing armamentarium of pulse sequences, MRI may ultimately become the modality of choice for cardiac imaging. Because cardiac imaging is relatively unknown territory for most radiologists and because the high-end equipment has until now been sparsely available, CMR has been largely limited to major medical centers. However, if sufficient interest is present and resources are appropriately allocated, CMR can be successfully implemented in community imaging practices.

Comprehensive cardiac magnetic resonance imaging at 3.0 Tesla: feasibility and implications for clinical applications

OBJECTIVE

The objective of this study was to examine the applicability of high magnetic field strengths for comprehensive functional and structural cardiac magnetic resonance imaging (MRI).

SUBJECTS AND METHODS

Eighteen subjects underwent comprehensive cardiac MRI at 1.5 T and 3.0 T. The following imaging techniques were implemented: double and triple inversion prepared FSE for anatomic imaging, 4 different sets of echocardiographic-gated CINE strategies for functional and flow imaging, inversion prepared gradient echo for delayed enhancement imaging, T1-weighted segmented EPI for perfusion imaging and 2-dimensional (2-D) spiral, and volumetric SSFP for coronary artery imaging.

RESULTS

: Use of 3 Tesla as opposed to 1.5 Tesla provided substantial baseline signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) improvements for anatomic (T1-weighted double IR: DeltaSNR = 29%, DeltaCNR = 20%, T2-weighted double IR: DeltaSNR = 39%, DeltaCNR = 33%, triple IR: DeltaSNR = 74%, DeltaCNR = 60%), functional (conventional CINE: DeltaSNR = 123%, DeltaCNR = 74%, accelerated CINE: DeltaSNR = 161%, DeltaCNR = 86%), myocardial tagging (DeltaSNRsystole = 54%, DeltaCNRsystole = 176%), phase contrast flow measurements (DeltaSNR = 79%), viability (DeltaSNR = 48%, DeltaCNR = 40%), perfusion (DeltaSNR = 109%, DeltaCNR = 87%), and breathhold coronary imaging (2-D spiral: DeltaSNRRCA = 54%, DeltaCNRRCA = 69%, 3-D SSFP: DeltaSNRRCA = 60%, DeltaCNRRCA = 126%), but also revealed image quality issues, which were successfully tackled by adiabatic radiofrequency pulses and parallel imaging.

CONCLUSIONS

Cardiac MRI at 3.0 T is feasible for the comprehensive assessment of cardiac morphology and function, although SAR limitations and susceptibility effects remain a concern. The need for speed together with the SNR benefit at 3.0 T will motivate further advances in routine cardiac MRI while providing an image-quality advantage over imaging at 1.5 Tesla.

Multimodal imaging of the sonic organ of Porichthys notatus, the singing midshipman fish

The sonic midshipman fish, Porichthys notatus, is a bottom-dwelling species whose swim bladder has evolved into a highly specialized, sound-producing organ. The males of this species exist in two distinct morphs with different physical characteristics and sexual strategies. The Type I males have a much larger sound organ and are capable of generating a loud approximately 100 Hz tone continuously for over an hour to attract females. This sound is produced by sonic muscle and represents one of the most superfast and super-enduring striated muscles found in nature. Each fiber contains a hollow, tubular contractile apparatus composed of radially arranged myofibrils with extremely broad Z-bands that are supported by a desmin-rich cytoskeleton. We have used micro computed tomography (CT) imaging and magnetic resonance (MR) imaging to visualize the location of the sonic organ in an intact male fish. We have also obtained high-resolution MR images of the excised swim bladders from both male types. The images of the Type I sonic organ are strikingly detailed and high-contrast, revealing both the internal organization of the bladder and the crisscrossing muscle fibers and their mode of attachment to the underlying bladder. The high-contrast variation in these images is due to different T(2) values for fiber bundles and the spaces between the bundles. Direct MR imaging of intact Type I sonic organ in Type I midshipman fish is a powerful approach to understanding the contraction of this superfast muscle and the oscillation of its bladder to produce mating calls, and how placement of the sonic organ in the body of the fish sheds light on its prodigious ability to produce and transmit its loud mating call.

Dobutamine cardiovascular magnetic resonance: A review

Dobutamine cardiovascular magnetic resonance (DCMR) is useful for identifying myocardial ischemia and viability in patients with known or suspected coronary artery disease (CAD). This article reviews the performance and utility of DCMR, its association with dobutamine stress echocardiography (DSE), and areas of active investigative research.

Influence of high magnetic field strengths and parallel acquisition strategies on image quality in cardiac 2D CINE magnetic resonance imaging: comparison of 1.5 T vs. 3.0 T

The aim of this paper is to examine signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR) and image quality of cardiac CINE imaging at 1.5 T and 3.0 T. Twenty volunteers underwent cardiac magnetic resonance imaging (MRI) examinations using a 1.5-T and a 3.0-T scanner. Three different sets of breath-held, electrocardiogram-gated (ECG) CINE imaging techniques were employed, including: (1) unaccelerated SSFP (steady state free precession), (2) accelerated SSFP imaging and (3) gradient-echo-based myocardial tagging. Two-dimensional CINE SSFP at 3.0 T revealed an SNR improvement of 103% and a CNR increase of 19% as compared to the results obtained at 1.5 T. The SNR reduction in accelerated 2D CINE SSFP imaging was larger at 1.5 T (37%) compared to 3.0 T (26%). The mean SNR and CNR increase at 3.0 T obtained for the tagging sequence was 88% and 187%, respectively. At 3.0 T, the duration of the saturation bands persisted throughout the entire cardiac cycle. For comparison, the saturation bands were significantly diminished at 1.5 T during end-diastole. For 2D CINE SSFP imaging, no significant difference in the left ventricular volumetry and in the overall image quality was obtained. For myocardial tagging, image quality was significantly improved at 3.0 T. The SNR reduction in accelerated SSFP imaging was overcompensated by the increase in the baseline SNR at 3.0 T and did not result in any image quality degradation. For cardiac tagging techniques, 3.0 T was highly beneficial, which holds the promise to improve its diagnostic value.

Assessment of Left Ventricular Torsional Deformation by Doppler Tissue Imaging

Background— Left ventricular (LV) torsional deformation is a sensitive index for LV performance but difficult to measure. The present study tested the accuracy of a novel method that uses Doppler tissue imaging (DTI) for quantifying LV torsion in humans with tagged magnetic resonance imaging (MRI) as a reference.

Methods and Results— Twenty patients underwent DTI and tagged MRI studies. Images of the LV were acquired at apical and basal short-axis levels to assess LV torsion. We calculated LV rotation by integrating the rotational velocity, determined from DTI velocities of the septal and lateral regions, and correcting for the LV radius over time. LV torsion was defined as the difference in LV rotation between the 2 levels. DTI rotational and torsional profiles throughout systole and diastole were compared with those by tagged MRI at isochronal points. Rotation and torsion by DTI were closely correlated with tagged MRI results during systole and early diastole (apical and basal rotation, r =0.87 and 0.90, respectively; for torsion, 0.84; P <0.0001, by repeated-measures regression models). Maximal torsion showed even better correlation ( r =0.95, P <0.0001).

Conclusions— The present study has shown that DTI can quantify LV torsional deformation over time. This novel method may facilitate noninvasive quantification of LV torsion in clinical and research settings.

Steady-state free precession MR imaging: improved myocardial tag persistence and signal-to-noise ratio for analysis of myocardial motion

Tagging with balanced steady-state free-precession (SSFP) magnetic resonance (MR) imaging by using a steady-state storage scheme for myocardial motion analysis was evaluated. Signal-to-noise ratio (SNR), blood-tissue contrast, and tag persistence in volunteers and phantoms showed improved performance of SSFP imaging with tagging compared with that of radiofrequency spoiled gradient-echo (SPGR) MR imaging with tagging. Choice of flip angle with SSFP imaging involved a trade-off among SNR, blood-tissue contrast, and tag persistence. Increased SNR and tag persistence can be achieved simultaneously with SSFP imaging compared with SPGR tagging methods. As a result, the proposed technique may be useful for analysis of diastolic ventricular function.

Complementary results of computed tomography and magnetic resonance imaging of the heart and coronary arteries: a review and future outlook

MR and CT imaging are emerging as promising complementary imaging modalities in the primary diagnosis of CAD and for the detection of subclinical atherosclerotic disease. For the detection or exclusion of significant CAD, both cardiac CT (including coronary calcium screening and non-invasive coronary angiography), and cardiac MRI (using stress function and stress perfusion imaging) are becoming widely available for routine clinical evaluation. Their high negative predictive value, especially when combining two or more of these modalities, allows the exclusion of significant CAD with high certainty, provided that patients are selected appropriately. The primary goal of current investigations using this combined imaging approach is to reduce the number of unnecessary diagnostic coronary catheterizations, and not to replace cardiac catheterization altogether. For the diagnosis of obstructive coronary atherosclerosis and for screening for subclinical disease, CT and MRI have shown potential to directly image the atherosclerotic lesion, measure atherosclerotic burden, and characterize the plaque components. The information obtained may be used to assess progression and regression of atherosclerosis and may open new areas for diagnosis, prevention, and treatment of coronary atherosclerosis. Further clinical investigation is needed to define the technical requirements for optimal imaging, develop accurate quantitative image analysis techniques, outline criteria for image interpretation, and define the clinical indications for both MR or CT imaging. Additional studies are also needed to address the cost effectiveness of such a combined approach versus other currently available imaging modalities.

MR and CT assessment for ischemic cardiac disease

Magnetic resonance imaging and/or contrast-enhanced multidetector computed tomography may be used separately or, often more effectively, in an integrated fashion, to address important issues in patients with coronary artery disease causing ischemic cardiac disease (ICD). These issues include complications of myocardial infarction, such as ventricular dysfunction, myocardial wall rupture, aneurysm formation, intracavitary thrombus, mitral insufficiency, and pericarditis, as well as aspects of planning and monitoring therapy for ICD, such as revascularization and ventricular aneurysm repair.

Imaging of pericardial disease

Pericardial pathology is most often identified by its effect on cardiac function. Echocardiography is usually performed first in evaluation of pericardial disease, but is occasionally limited or indeterminate. MR imaging is often helpful in these cases, offering superior soft tissue contrast and the ability to image the entire pericardium and its relationship to cardiac structure and function. Many of the techniques recently developed for myocardial imaging are equally applicable to the pericardium and frequently assist in the diagnosis of pericardial disease. In this article, the authors review MR imaging techniques for pericardial imaging, discuss the appearance of the normal pericardium, and illustrate pathologic and congenital conditions of the pericardium.

Ethical considerations in image-based screening for coronary artery disease

Despite marked advances in the treatment and prevention of coronary artery disease (CAD) during the last decade, CAD and its complications continue to account for 20% of all deaths in the United States, more than other cause of death. Moreover, half of those who die suddenly of an acute myocardial infarction have no prior symptoms or overt manifestations of their underlying CAD. As our understanding of the pathophysiology of coronary atherosclerosis improves, diagnostic tests utilizing magnetic resonance (MR) imaging and gated computed tomography are being developed to screen for significant CAD in symptomatic individuals and in those who are preclinical or asymptomatic. Patients with known or suspected CAD might be candidates for MR studies of myocardial perfusion, myocardial contraction under stress, MR coronary arteriography, and plaque characterization. One rationale would be to uncover patients before they have a silent heart attack to institute preventative therapies. Although clinical studies have not definitively demonstrated the efficacy of these modalities, screening sites are proliferating and patients are demanding screening tests for CAD. Radiologists interpreting these tests should understand their underlying rationale, the data referenced to substantiate their use, and their responsibility to inform the patient of the results. This review describes current concepts of the pathophysiology of CAD, the rationale for the various screening tests for CAD that are in use or in development, and the potential value of the results of screening to individual patients. The ethical issues embodied in the performance of screening tests for CAD are placed in the context of the appropriate role of the radiologist as a physician interacting directly with a patient.

The structure and function of the helical heart and its buttress wrapping. IV. Concepts of dynamic function from the normal macroscopic helical structure

Torrent-Guasp's model of the helical heart is presented, which includes the cardiac muscular structures that produce 2 simple loops and that start at the pulmonary artery and end in the aorta. These components include a horizontal basal loop that surrounds the right and left ventricles, changes direction through a spiral fold in the ventricular band to cause a ventricular helix produced by now obliquely oriented fibers, forming a descending and ascending segment of the apical loop with an apical vortex. These anatomic concepts are successively activated to produce a sequence of narrowing by the basal loop, shortening by the descending segment, lengthening by the ascending segment, and widening in the cardiac cycle that causes ventricular ejection to empty and suction to fill. The factors responsible for internal torsional movements for cardiac output and suction are defined, together with mechanisms responsible for electromechanical activity produced during sequential changes in contraction and relaxation properties. These interactions of mechanical structure and function are defined in relation to pressure-related cardiac events observed from aortic, left ventricular, and left atrial recordings.

The structure and function of the helical heart and its buttress wrapping. I. The normal macroscopic structure of the heart

The Gordian knot of anatomy has been the architectural arrangement of ventricular muscle mass, which may have finally become understood. The description of Francisco Torrent-Guasp's model of the helical heart is presented, which includes the cardiac structures that produce 2 simple loops that start at the pulmonary artery and end in the aorta. An unscrolled ventricular band is shown, achieved by blunt dissection that extends between the points of origin of the right ventricle, at the pulmonary artery root, to termination at the aortic root, in the left ventricle. These components include a spiral horizontal basal loop that surrounds the right and left ventricular cavities, and changes direction to cause a second spiral, produced by almost vertically oriented fibers, giving rise to the helical configuration of the ventricular myocardial band. These anatomic structures are successively activated, as with a peristaltic wave, starting at the right ventricle (just below the pulmonary artery) and progressing toward the aorta to produce a sequence of narrowing, caused by the basal loop contraction, shortening (related predominantly to the descendant segment contraction), lengthening (produced by the ascendant segment contraction), and widening, as a consequence of several factors that act during ventricular myocardium relaxation. These sequences control the ventricular events responsible for ejection to empty and suction to fill. These mechanical interactions of structure and function are defined in relation to chronologic location of the successive cardiac functional events in the aortic, left ventricular, and left atrial recordings.

MR imaging of congenital heart diseases in adolescents and adults

Echocardiography and catheterization angiography suffer certain limitations in the evaluation of congenital heart diseases in adults, though these are overcome by MRI, in which a wide field-of view, unlimited multiplanar imaging capability and three-dimensional contrast-enhanced MR angiography techniques are used. In adults, recently introduced fast imaging techniques provide cardiac MR images of sufficient quality and with less artifacts. Ventricular volume, ejection fraction, and vascular flow measurements, including pressure gradients and pulmonary-to-systemic flow ratio, can be calculated or obtained using fast cine MRI, phase-contrast MR flow-velocity mapping, and semiautomatic analysis software. MRI is superior to echocardiography in diagnosing partial anomalous pulmonary venous connection, unroofed coronary sinus, anomalies of the pulmonary arteries, aorta and systemic veins, complex heart diseases, and postsurgical sequelae. Biventricular function is reliably evaluated with cine MRI after repair of tetralogy of Fallot, and Senning's and Mustard's operations. MRI has an important and growing role in the morphologic and functional assessment of congenital heart diseases in adolescents and adults.